FAX COVER SHEET Effective 10/2012 NEW PATIENT REFERRAL/REQUEST FOR INSURANCE BENEFITS Date: _____________ To: Attn: Phone#: Fax#: Number of pages: _______ (including cover sheet) Luna Medical, Inc. Patient Referrals Dept. 1-800-380-4339 1-888-696-0299 From: Clinic: Phone#: Fax#: (First name, Last name) (xxx-xxx-xxxx) (xxx-xxx-xxxx) Patient name: ____________________________ PLEASE INCLUDE THE INFORMATION REQUESTED BELOW FORMS (1-4) ARE SUPPLIED BY LUNA MEDICAL. ALL REFERRAL AND MEASURING FORMS CAN BE ACCESSED ON OUR WEBSITE AT www.lunamedical.com *PLEASE INCLUDE CLINICAL HISTORY FORM FOR INSURANCE VERIFICATION *ANTICIPATED MEDICAL PRODUCTS (PLEASE CIRCLE): JUZO JOBST MEDI CIRCAID JOVI TRIBUTE REIDSLEEVE LYMPHAPRESS *WE DO NOT CONTACT THE PATIENT UNTIL WE HAVE RECEIVED MEASUREMENTS. PLEASE USE MEASUREMENT FORMS ON OUR WEBSITE. THESE FORMS ARE CONTINUALLY UPDATED BY THE MANUFACTURERS. CHECKLIST: 1) 2) 3) 4) 5) Patient Data/Contact form Patient Clinical History form Notice of Privacy Practices form Measurement form(s) for product(s) ordered Copy of patient insurance card *front and back; please enlarge, if possible 6) Copy of Patient Facesheet from your clinic 7) Your initial evaluation *can be requested when obtaining authorizations for patients that DO NOT have a history of cancer surgery and/or radiation *Luna Medical will obtain a Certificate of Medical Necessity from the Referring doctor listed on the Patient Data/Contact form. Special Requests/Comments: ________________________________________________________ Notice: The information contained in this facsimile transmission is confidential and intended for the personal use of the person named above as the addressee. If the reader of this message is not the intended recipient, or the employee of the agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this message communication is strictly prohibited. It may be a violation of the confidentiality sections of the U.S. Internal Revenue code or state statutes and could be subject to legal action. If you have received this communication in error, please notify us by phone and return the original message to us at the address shown above.